Get Ks Av1m 2016

Affirmation Affirmation of an Elector of the County of and State of Kansas Desiring to Vote an Advance Voting Ballot State of County of ss where application is completed 2. Selecting Print will print the form and Reset will reset the entire form. Application for Advance Ballot by Mail DOWNLOAD THIS FORM AT WWW.SOS.KS.GOV FORM AV1M 1. I am entitled to vote an advance voting ballot and I have not voted and will not otherwise vote at the election to be held on Required Signature of Voter Date MM/DD/YY Phone Number FOR OFFICE USE ONLY Date App. Rec d. Reset Print Office of the Kansas Secretary of State Please complete the form sign and send to the Kansas Secretary of State. Voter Identification Requirements I understand that my current and valid Kansas driver s license number or Kansas nondriver s identification card number must be provided in order to receive a ballot. Current Kansas driver s license number or nondriver s identification card number If I do not have a current and valid Kansas driver s license number or Kansas nondriver s identification card number I must provide a copy of one of the following forms of photo identification with this application in order to receive a ballot. Driver s license issued by Kansas or another state Nondriver s ID card issued by Kansas or another state U*S* passport Concealed carry of handgun license issued by Kansas or another state Employee badge or ID document issued by a government office 3. Personal Information U*S* military ID Student ID card issued by an accredited Kansas postsecondary educational institution Public assistance ID card issued by a government office ID card issued by an Indian tribe Please print* Last Name First Name M. I. Date of Birth MM/DD/YY Residential Address City State Zip Code Political Party To be filled in only when requesting a primary election ballot Democratic Republican 4. Address to Mail Ballot if different from residential address Mailing Address Note The ballot may be mailed only to the voter s residential or mailing address as indicated on the county voter registration list to the voter s temporary residential address or to a medical care facility where the voter resides. These restrictions do not apply to a voter who has an illness disability or who lacks proficiency in the English language. Ballots cannot be mailed until 20 days before the election* 5. Voter Signature Note False statement on this affirmation is a severity level 9 nonperson felony. I do solemnly affirm under penalty of perjury that I am a qualified elector residing at the address listed above. Ballot Mailed Transmitted by Prepared by the Office of Secretary of State Kris W* Kobach 1st Floor Memorial Hall 120 S*W* 10th Avenue Topeka KS 66612-1594. KSA 25-1122d a. Rev 6/11/14 tc Allen County 1 N Washington Iola KS 66749 Phone 620 365-1407 Fax 620 365-1441 Anderson County 100 E 4th Garnett KS 66032 Phone 785 448-6841 Fax 785 448-3205 Atchison County 423 N 5th Atchison KS 66002-1861 Phone 913 367-1653 Fax 913 367-0227 Barber County Medicine Lodge KS 67104 Phone 620 886-3961 Fax 620 886-5425 Barton County Room 202 1400 Main St* Great Bend KS 67530 Phone 620 793-1835 Fax 620 793-1990 Bourbon County 210 S National Ft Scott KS 66701 Phone 620 223-3800 Fax 620 223-5832 601 Oregon St Hiawatha KS 66434 Phone 785 742-2581 Fax 785 742-7705 Butler County 205 W Central Courthouse El Dorado KS 67042 Phone 316 322-4233 Fax 316 321-1011 Chase County PO Box 529 Cottonwood Falls KS 66845-0547 Phone 620 273-6423 Fax 620 273-6617 Chautauqua County 215 N Chautauqua Sedan KS 67361 Phone 620 725-5800 Fax 620 725-5801 Cherokee County PO Box 14 100 W Maple Columbus KS 66725 Phone 620 429-2042 Fax 620 429-1042 Cheyenne County PO Box 985 212 E St Francis KS 67756 Phone 785 332-8800 Fax 785 332-8825 Clark County PO Box 886 913 Highland Ashland KS 67831 Phone 620 635-2813 Fax 620 635-2051 PO Box 98 712 5th St* Clay Center KS 67432 Phone 785 632-2552 Fax 785 632-5856 Cloud County Concordia KS 66901 Phone 785 243-8110 Fax 785 243-8123 Coffey County Room 202 110 S 6th Burlington KS 66839 Phone 620 364-2191 Fax 620 364-8975 Comanche County Box 776 201 S New York Coldwater KS 67029 Phone 620 582-2361 Fax 620 582-2426 311 E 9th Winfield KS 67156 Phone 620 221-5495 Fax 620 221-5498 Crawford County PO Box 249 111 E Forest Girard KS 66743-0249 Phone 620 724-6115 Fax 620 724-6007 Decatur County PO Box 28 Oberlin KS 67749 Phone 785 475-8102 Fax 785 475-8150 Dickinson County PO Box 248 109 E 1st Ste.